Subarachnoid Hemorrhage Following Ischemic Stroke Caused by Atrial Myxoma

Subarachnoid hemorrhage (SAH) is a rare neurological complication of cardiac myxoma and is associated with poor outcomes. Previous reports have shown that myxoma-associated SAH was contributed by rupture of myxomatous intracerebral aneurysm. Here, we present an unusual case of angiographic-negative SAH in a young patient with left atrial myxoma.  A 28-year-old male was admitted for SAH. He had a history of magnetic resonance imaging (MRI)-confirmed ischemic stroke one year ago. The digital subtraction angiography (DSA) performed on next day revealed no intracerebral aneurysm or vascular malformation. Transthoracic echocardiography (TTE) showed a left atrial mass measuring 5.09 * 3.34 cm, indicating a diagnosis of atrial myxoma, which was confirmed by pathological examination. The cardiac tumor was excised and the patient's symptoms improved completely. No intracerebral aneurysm was found by brain computed tomographic angiography (CTA) performed on day 24 after onset and one year after discharge. The patient remained asymptomatic during the one-year following-up. The result suggests that SAH may be more commonly associated with cardiac myxoma than previously expected. And, mechanisms other than rupture of myxomatous intracerebral aneurysm involve in SAH associated with cardiac myxoma. Prolonged length of following-up using novel imaging technique should be applied to identify and monitor the change of source bleeding.